Provider Demographics
NPI:1164875753
Name:EDWARDS, KACIE ELLEN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:ELLEN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:12117-0588
Mailing Address - Country:US
Mailing Address - Phone:518-774-3558
Mailing Address - Fax:
Practice Address - Street 1:101 SANFORD FARMS SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-7535
Practice Address - Country:US
Practice Address - Phone:518-774-3558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist